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New research “fails to show that youth vaping causes future smoking,” announces the University of Massachusetts Amherst. Hold the front page (and open the champagne if you’re a harm-reduction advocate)?
Not so quick, perhaps, because one of the more significant things about the study is precisely that it “fails to show”. It does not demonstrate anywhere near conclusively the absence of a link between youth vaping and the later take-up of combustibles; it just doesn’t find any overwhelming evidence for a link. And this, although it might be disappointing for the researchers (who would presumably have liked a more definitive takeaway), illustrates several of the issues that have long plagued the intersection of tobacco harm reduction (THR), science and public policy.
We have seen them mostly in the arena of vaping, because it’s been a mainstream consumer product longer than other forms of THR, but we can certainly expect exactly the same issues to arise with nicotine pouches if – or when – their use among young people grows. (A surge in teenage use of heated tobacco products seems less likely for a number of reasons, including their greater similarity to combustible cigarettes, their more obvious role as a replacement product for smokers, the limited range of flavours available and the inherently somewhat clunkier design with its quickly exhausted consumables.)
Review of existing research
Now, it needs to be said up front that the “failure” of this research to show anything is not in any sense the fault of the researchers, led by Amherst’s Jamie Hartmann-Boyce, an assistant professor of health policy and management, who will be familiar to many people on the THR scene. (It will probably not occupy as prominent a place on her curriculum vitae as her academic papers, but a few years back she co-wrote a song called The Great Vape Debate; we have, thus far, failed to confirm that it is being developed into a full-blown Broadway musical, with Michael Bloomberg soloing in the big number “How do You Solve a Problem Like Altria?”.)
Their paper, entitled “Electronic cigarettes and subsequent cigarette smoking in young people” and published in the journal Addiction, is a “systematic review” of already existing research – in other words, they didn’t talk to young vapers and smokers themselves to produce this paper, but instead brought together the findings of many other studies (more than 120 in all, mostly US-based and covering up to 4.5m people, although the exact total is indeterminable because of possible duplication).
In these, they then looked to see what evidence there was for the availability or use of e-cigarettes correlating with the adoption of smoking by people under 30. They were willing to consider large-scale statistics representative of a population generally, such as changes in the overall smoking rate of this group, and the reported behaviour of individuals.
Interpretation is in the eye of the beholder
One of the major issues they ran into, however, is one that affects so much research in the THR area. “The studies themselves are not straightforward study designs, because you can’t randomize kids to vape or not vape – it just wouldn’t be ethical,” Hartmann-Boyce observed. That is to say, you can’t actually ask young people to use e-cigarettes and then see if they start smoking later on in life; you can only go on what actually happened to them in their lives in the real world, with all its mess of potential causative factors and potential inhibitors.
And this, she added, “means that there are so many different ways to interpret the findings of these studies”. Or, as the Addiction paper puts it, “the only thing that can be said with certainty is that the evidence is not certain”.
This is a persistent difficulty with research into the linkage (if any) between vaping and smoking, and it is exacerbated by the natural desire of people on both sides of the THR argument to want definitive answers. Advocates of one position or the other grasp desperately for them, yet research so far has not provided them. Indeed, the very tentative conclusions of this systematic review might, in themselves, seem contradictory.
Funding needed to clear muddy waters
At the level of whole populations, Hartmann-Boyce and colleagues found evidence, albeit “very low certainty evidence”, of an inverse relationship between the availability or use of vapes and the rate of smoking among young people – in crude terms, the more vaping there is, the less smoking.
Yet “at an individual level, people who vape appear to be more likely to go on to smoke than people who do not vape [though] it is unclear if these behaviours are causally linked”. The paper drily observes that, while there are several competing theories as to how vaping and the take-up (or non-take-up) of smoking might interact, “a lack of empirical support for these hypotheses persists”.
So, no clear answers at all. Moreover, the researchers note that “no studies were judged to be at low overall risk of bias” – which generally means issues that might distort those studies’ findings rather than deliberate manipulation – and that studies of young people’s vaping and smoking have been dominated by the US and higher-income countries in general.
Hartmann-Boyce and her colleagues, even if they didn’t come up with the answers everyone is looking for, do a useful service by highlighting all this. Maybe their work will even help to encourage research that leads to more certainty (and the funding for such research) rather than adding further mud to already muddy waters. In the meantime, though, we can expect more cherry-picking of data that supports policy positions – on e-cigarettes, and doubtless soon on nicotine pouches too.
– Barnaby Page TobaccoIntelligence staff
Photo: Jared Subia
